A Physiatric Approach to Falls and Fall Prevention Brad Steinle, M.D. January 16, 2009
Scope of the Problem <ul><li>Falls are the leading cause of fatal and nonfatal injuries to older people in the U.S. </li><...
Scope of the Problem <ul><li>Others sustain soft tissue injury, upper limb fracture, subdural hematoma. </li></ul><ul><li>...
Falls Tend to be Multifactorial <ul><li>Intrinsic Factors </li></ul><ul><ul><li>Medical conditions </li></ul></ul><ul><ul>...
Medical Conditions <ul><li>Neurologic </li></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Parkinson’s </li></ul></ul><...
Normal Consequences of Aging <ul><li>Neurologic </li></ul><ul><ul><li>Increased reaction time </li></ul></ul><ul><ul><li>D...
Age-Related Changes with Gait <ul><li>Slower gait (Slower gait associated with increased falls). </li></ul><ul><li>Decreas...
Loss of Mobility <ul><li>Dysmobility and falling closely related. </li></ul><ul><li>15% of those over 65 have trouble walk...
Medications <ul><li>Fall risk increases with 4 or more medications. </li></ul><ul><li>Sedative-hypnotics, especially long ...
Extrinsic Factors <ul><li>Environmental Factors: </li></ul><ul><ul><ul><li>Poor lighting </li></ul></ul></ul><ul><ul><ul><...
Extrinsic Factors <ul><li>Some patients will only have safe gait with an assistive device. </li></ul><ul><ul><li>Walkers <...
Most common risk factors in 16 studies <ul><li>Muscle weakness. </li></ul><ul><li>History of falls. </li></ul><ul><li>Gait...
Evaluation - History <ul><li>Where did you fall – home, work, outside, sidewalk? </li></ul><ul><li>When did you fall – day...
Evaluation - History <ul><li>Review past medical history – any history of stroke, Parkinson’s, diabetes, CAD, osteoarthrit...
Examination <ul><li>General – check sitting and standing BP. </li></ul><ul><li>Neuromuscular: </li></ul><ul><ul><li>Streng...
Examination <ul><li>Skeletal </li></ul><ul><ul><li>Kyphosis </li></ul></ul><ul><ul><li>Valgus and varus deformity of the k...
Examination <ul><li>Proprioception testing especially important if history of neuropathy. </li></ul><ul><li>Romberg’s test...
Examination <ul><li>Strength </li></ul><ul><ul><li>Arms – shoulder abduction/flexion, elbow flexion/extension, grip. </li>...
Examination <ul><li>Observe sit to stand transfers </li></ul><ul><ul><li>Slow or fast </li></ul></ul><ul><ul><li>Any stumb...
Examination <ul><li>Have patient do single leg stance. </li></ul><ul><ul><li>Should be able to maintain balance for at lea...
Examination <ul><li>Observe Gait – not just in exam room.  Have patient do tandem gait, toe and heel walk. </li></ul><ul><...
Treatment <ul><li>If polypharmacy, look at reducing meds. </li></ul><ul><li>Decrease use of sedative agents. </li></ul>
Treatment <ul><li>Environmental </li></ul><ul><ul><li>Get rid of the throw rug. </li></ul></ul><ul><ul><li>Rails for steps...
Treatment <ul><li>Physical Therapy  </li></ul><ul><ul><li>Be specific with orders – if a strength problem; work to improve...
Balance Master Training
Treatment <ul><li>Community-based programs </li></ul><ul><ul><li>Tai Chi. </li></ul></ul><ul><ul><li>Regular walking progr...
Resistance Training
Cardiovascular Exercise
Tai Chi
<ul><li>JC is a 61 year old male with a 6 year history of Parkinson’s. </li></ul><ul><li>Has lived alone and has had incre...
<ul><li>Was evaluated by neurology and medication was switched from ropinirole to carbidopa/levadopa and admitted to the r...
Case #2 <ul><li>DK is 58 year old female who was referred for stumbling gait and several falls walking up steps. </li></ul...
Case #2 Continued <ul><li>She was referred to orthotist for fitting with bilateral ankle-foot orthoses and sent to therapy...
Case #3 <ul><li>PJ is a 69 year old female who was referred for difficulty with walking and several falls. </li></ul><ul><...
Case #3 Continued <ul><li>She was diagnosed with post-polio syndrome.  Her hip flexors had weakened and she had more diffi...
Case #4 <ul><li>SM was a 79 year old male who was referred for evaluation he had three falls in the past months.  </li></u...
Case #4 Continued <ul><li>He didn’t have a specific diagnosis but was referred to physical therapy for “Gait Disturbance”a...
Questions <ul><li>(True/False)  Decreased usual walking speed in the elderly is associated with decreased risk of falls. <...
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SLH Medical Grand Rounds - Dr Brad Steinle - Falls and Fall Prevention

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SLH Medical Grand Rounds - Dr Brad Steinle - Falls and Fall Prevention

  1. 1. A Physiatric Approach to Falls and Fall Prevention Brad Steinle, M.D. January 16, 2009
  2. 2. Scope of the Problem <ul><li>Falls are the leading cause of fatal and nonfatal injuries to older people in the U.S. </li></ul><ul><li>More than 1/3 of adults over the age of 65 years fall each year. </li></ul><ul><li>323,884 hip fractures occurred in 2003 in the U.S. </li></ul><ul><li>Between 18-33% of older hip fracture patients die within 1 year of their fracture. </li></ul>
  3. 3. Scope of the Problem <ul><li>Others sustain soft tissue injury, upper limb fracture, subdural hematoma. </li></ul><ul><li>Over $20 billion spent in medical costs annually for the treatment and complications associated with falls. </li></ul><ul><li>Any where to 25 to 75% previously independent seniors lose independence or fail to return to previous level of independence. </li></ul>
  4. 4. Falls Tend to be Multifactorial <ul><li>Intrinsic Factors </li></ul><ul><ul><li>Medical conditions </li></ul></ul><ul><ul><li>Vision changes </li></ul></ul><ul><ul><li>Age-related changes </li></ul></ul><ul><li>Extrinsic Factors </li></ul><ul><ul><li>Medications </li></ul></ul><ul><ul><li>Environment </li></ul></ul><ul><ul><li>Improper (lack of) use of assistive devices </li></ul></ul>
  5. 5. Medical Conditions <ul><li>Neurologic </li></ul><ul><ul><li>Stroke </li></ul></ul><ul><ul><li>Parkinson’s </li></ul></ul><ul><ul><li>Multiple Sclerosis </li></ul></ul><ul><ul><li>Neuropathies </li></ul></ul><ul><ul><li>Myopathies </li></ul></ul><ul><ul><li>Dementia </li></ul></ul><ul><ul><li>Depression </li></ul></ul><ul><ul><li>Hydrocephalus </li></ul></ul><ul><ul><li>Polio (Post-Polio Syndrome) </li></ul></ul><ul><li>Medical </li></ul><ul><ul><li>Cardiac Diseases </li></ul></ul><ul><ul><li>Osteoarthritis </li></ul></ul><ul><ul><li>Osteoporosis </li></ul></ul><ul><ul><li>Cataracts </li></ul></ul><ul><ul><li>Macular Degeneration </li></ul></ul><ul><ul><li>Diabetes </li></ul></ul><ul><ul><li>Joint Replacement </li></ul></ul>
  6. 6. Normal Consequences of Aging <ul><li>Neurologic </li></ul><ul><ul><li>Increased reaction time </li></ul></ul><ul><ul><li>Decreased righting reflexes </li></ul></ul><ul><ul><li>Decreased proprioception </li></ul></ul><ul><li>Vision Changes </li></ul><ul><ul><li>Decreased accommodation & dark adaptation </li></ul></ul><ul><li>Decreased muscle mass </li></ul>
  7. 7. Age-Related Changes with Gait <ul><li>Slower gait (Slower gait associated with increased falls). </li></ul><ul><li>Decreased stride length and arm swing. </li></ul><ul><li>Forward flexion at head and torso. </li></ul><ul><li>Increased flexion at shoulders and knees. </li></ul><ul><li>Increased lateral sway. </li></ul>
  8. 8. Loss of Mobility <ul><li>Dysmobility and falling closely related. </li></ul><ul><li>15% of those over 65 have trouble walking. </li></ul><ul><li>1/4 men and 1/3 women over age 85 have difficulty with walking. </li></ul><ul><li>2/3 of people in hospital or NH unable to ambulate without assistance. </li></ul>
  9. 9. Medications <ul><li>Fall risk increases with 4 or more medications. </li></ul><ul><li>Sedative-hypnotics, especially long acting benzodiazepines, increase falls. </li></ul><ul><li>Small association between most psychotropics and falls. </li></ul><ul><li>SSRIs and TCAs both increase falls. </li></ul><ul><li>Weak association between Type 1A antiarrythmics, digoxin, diuretics, and falls. </li></ul><ul><li>Antihypertensives. </li></ul><ul><li>Hypoglycemic agents. </li></ul>
  10. 10. Extrinsic Factors <ul><li>Environmental Factors: </li></ul><ul><ul><ul><li>Poor lighting </li></ul></ul></ul><ul><ul><ul><li>Unsafe stairways </li></ul></ul></ul><ul><ul><ul><li>Irregular floor surfaces </li></ul></ul></ul>
  11. 11. Extrinsic Factors <ul><li>Some patients will only have safe gait with an assistive device. </li></ul><ul><ul><li>Walkers </li></ul></ul><ul><ul><li>Canes </li></ul></ul><ul><ul><li>Ankle-foot orthoses </li></ul></ul>
  12. 12. Most common risk factors in 16 studies <ul><li>Muscle weakness. </li></ul><ul><li>History of falls. </li></ul><ul><li>Gait deficit. </li></ul><ul><li>Balance deficit. </li></ul><ul><li>Use of assistive device. </li></ul><ul><li>Visual deficit. </li></ul><ul><li>Arthritis. </li></ul><ul><li>Impaired ADL. </li></ul><ul><li>Depression. </li></ul><ul><li>Cognitive impairment. </li></ul><ul><li>Age > 80 years. </li></ul><ul><li>Guidelines for the prevention of falls in older person. JAGS 2001;49:664-672. </li></ul>
  13. 13. Evaluation - History <ul><li>Where did you fall – home, work, outside, sidewalk? </li></ul><ul><li>When did you fall – day/night, lights on/off? </li></ul><ul><li>Why did you fall – dizzy, lightheadness, trip, loss of consciousness, pet? </li></ul><ul><li>Have you fallen before? How many times? </li></ul><ul><li>Do you use a walker, cane – if so, did you fall with the device? </li></ul><ul><li>Did you hurt anything? </li></ul><ul><li>Try to confirm with spouse or family member. </li></ul>
  14. 14. Evaluation - History <ul><li>Review past medical history – any history of stroke, Parkinson’s, diabetes, CAD, osteoarthritis? </li></ul><ul><li>Review medications – focus on anything newly added. </li></ul><ul><li>Alcohol history – if suspected how much; shoot high. </li></ul><ul><li>Review exercise, therapy history. </li></ul>
  15. 15. Examination <ul><li>General – check sitting and standing BP. </li></ul><ul><li>Neuromuscular: </li></ul><ul><ul><li>Strength </li></ul></ul><ul><ul><li>Proprioception </li></ul></ul><ul><ul><li>Rombergs </li></ul></ul><ul><ul><li>Gait </li></ul></ul><ul><li>Skeletal – evaluate feet; knees, back, posture. </li></ul>
  16. 16. Examination <ul><li>Skeletal </li></ul><ul><ul><li>Kyphosis </li></ul></ul><ul><ul><li>Valgus and varus deformity of the knees. </li></ul></ul><ul><ul><li>Pronated foot </li></ul></ul>
  17. 17. Examination <ul><li>Proprioception testing especially important if history of neuropathy. </li></ul><ul><li>Romberg’s test </li></ul><ul><ul><li>Increased sway with eyes – think cerebellar. </li></ul></ul><ul><ul><li>Eyes closed – Posterior column abnormality. </li></ul></ul>
  18. 18. Examination <ul><li>Strength </li></ul><ul><ul><li>Arms – shoulder abduction/flexion, elbow flexion/extension, grip. </li></ul></ul><ul><ul><li>Legs – hip flexion/extension, knee flexion/extension, ankle dorsi-/plantar flexion; check hip abductors if dorsiflexors weak to differentiate proximal versus distal problem. </li></ul></ul><ul><ul><li>Check plantar flexion with calf raises. </li></ul></ul>
  19. 19. Examination <ul><li>Observe sit to stand transfers </li></ul><ul><ul><li>Slow or fast </li></ul></ul><ul><ul><li>Any stumbling? </li></ul></ul><ul><ul><li>Modified Gower’s </li></ul></ul>
  20. 20. Examination <ul><li>Have patient do single leg stance. </li></ul><ul><ul><li>Should be able to maintain balance for at least 10 seconds. </li></ul></ul><ul><li>Have patient do tandem stance. </li></ul><ul><ul><li>Should be able to maintain balance for at least 10 seconds. </li></ul></ul>
  21. 21. Examination <ul><li>Observe Gait – not just in exam room. Have patient do tandem gait, toe and heel walk. </li></ul><ul><ul><li>Trendelenberg – “Mae West” </li></ul></ul><ul><ul><li>Antalgic – osteoarthritis. </li></ul></ul><ul><ul><li>Steppage – weak dorsiflexors; excessive hip flexion. </li></ul></ul><ul><ul><li>Slapping gait – decreased proprioception; weak dorsiflexors. </li></ul></ul><ul><ul><li>Shuffling gait – Parkinson’s. </li></ul></ul><ul><ul><li>Observe posture – kyphosis; flexed hips. </li></ul></ul>
  22. 22. Treatment <ul><li>If polypharmacy, look at reducing meds. </li></ul><ul><li>Decrease use of sedative agents. </li></ul>
  23. 23. Treatment <ul><li>Environmental </li></ul><ul><ul><li>Get rid of the throw rug. </li></ul></ul><ul><ul><li>Rails for steps. </li></ul></ul><ul><ul><li>Use walker if needed. </li></ul></ul><ul><ul><li>Night lighting. </li></ul></ul>
  24. 24. Treatment <ul><li>Physical Therapy </li></ul><ul><ul><li>Be specific with orders – if a strength problem; work to improve – ask therapist to focus on functional strength (closed-kinetic chain exercises). </li></ul></ul><ul><ul><li>If a balance problem; look for programs that can focus on balance (can be found in vestibular rehabilitation programs). </li></ul></ul><ul><ul><li>Need plan to continue program in the community. </li></ul></ul>
  25. 25. Balance Master Training
  26. 26. Treatment <ul><li>Community-based programs </li></ul><ul><ul><li>Tai Chi. </li></ul></ul><ul><ul><li>Regular walking programs. </li></ul></ul><ul><ul><li>Aquatic exercise programs. </li></ul></ul><ul><ul><li>Resistance training programs – focus on functional movements (leg press). </li></ul></ul>
  27. 27. Resistance Training
  28. 28. Cardiovascular Exercise
  29. 29. Tai Chi
  30. 30. <ul><li>JC is a 61 year old male with a 6 year history of Parkinson’s. </li></ul><ul><li>Has lived alone and has had increased falls over the last 6 months. </li></ul><ul><li>Admitted to SLH with “Failure to thrive.” </li></ul>Case #1
  31. 31. <ul><li>Was evaluated by neurology and medication was switched from ropinirole to carbidopa/levadopa and admitted to the rehab unit for therapy and medication adjustment. </li></ul><ul><li>Over the next ten days, he went to moderate assist for transfers and unsteady gait to ambulating safely without cane or walker. </li></ul><ul><li>He stated he hadn’t functioned this well in 2 years. </li></ul>Case #1 Continued
  32. 32. Case #2 <ul><li>DK is 58 year old female who was referred for stumbling gait and several falls walking up steps. </li></ul><ul><li>Was evaluated and found to have weak dorsiflexors. </li></ul><ul><li>Electrodiagnostic study showed idiopathic peroneal neuropathy. </li></ul>
  33. 33. Case #2 Continued <ul><li>She was referred to orthotist for fitting with bilateral ankle-foot orthoses and sent to therapy for gait training. </li></ul><ul><li>She has had not further falls. </li></ul>
  34. 34. Case #3 <ul><li>PJ is a 69 year old female who was referred for difficulty with walking and several falls. </li></ul><ul><li>She had history of polio as a child and had left foot drop but had not required bracing. </li></ul><ul><li>Strength exam revealed the left leg to have weakened hip flexors (3/5) which was new; weakened knee extensor (3/5) and dorsiflexors (1/5). </li></ul>
  35. 35. Case #3 Continued <ul><li>She was diagnosed with post-polio syndrome. Her hip flexors had weakened and she had more difficulty clearing the left foot. </li></ul><ul><li>She was convinced to be fitted and wear a AFO. </li></ul><ul><li>She was referred to physical therapy and use of a single point cane was recommended. </li></ul><ul><li>She has had no further falls since using the AFO and SPC. </li></ul>
  36. 36. Case #4 <ul><li>SM was a 79 year old male who was referred for evaluation he had three falls in the past months. </li></ul><ul><li>History revealed no recent changes. He had a right TKA 2 years ago. Had a h/o CAD, HTN. </li></ul><ul><li>Exam revealed mildly tightened hip flexors, but normal strength and sensation. Gait mild forward flexion of the trunk. Single leg stance was 8-9 secs on each foot. </li></ul>
  37. 37. Case #4 Continued <ul><li>He didn’t have a specific diagnosis but was referred to physical therapy for “Gait Disturbance”and “Personal history of Falls.” </li></ul><ul><li>He underwent aggressive stretching to the hip flexors, lower limb strengthening and Balance program. </li></ul><ul><li>He was discharged with a home exercise program. </li></ul><ul><li>He has had no further falls. </li></ul>
  38. 38. Questions <ul><li>(True/False)  Decreased usual walking speed in the elderly is associated with decreased risk of falls. </li></ul><ul><li>(True/False)  Most falls in the elderly have a single, identifiable cause. </li></ul><ul><li>(True/False)  Single leg stance testing can be an easy and effective way to assess risk of falls. </li></ul>

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